**This report has been amended to include additional information that was not included in the original report. **

It was alleged that staff did not respond to resident’s call button in a timely manner and resident sustained numerous falls due to staff neglect. It was reported that Resident #1 (R1) attempts to transfer to the restroom or clean themselves after episodes of incontinence when staff do not respond in a timely manner. It was further reported that there are many instances in which staff do not respond promptly to R1’s calls for assistance, resulting in at least six (6) falls within the past six (6) months. Information gathered during the course of the investigation reflected that R1 sustained two (2) unwitnessed falls at the facility. The first unwitnessed fall occurred on 01/26/2026 and the second on 04/08/2026, R1, was sent out for medical evaluation and treatment for both cases. Interviews with staff reflected that R1 used a walker for mobility and was frequently reminded to use it. It was also revealed that R1 often attempted to independently use the restroom without requesting staff for assistance and did not use the walker. Moreover, following R1’s falls, staff communicated R1’s change in condition to R1’s POA/family and informed them that R1 would need increase in supervision. Record review of the facility’s Device Activity Report dated 04/01/2026 through 04/08/2026 further reflected that R1 pressed their call button fifty-nine (59) times. Of the total number of calls, only two (2) were answered after more than twenty (20) minutes. The remaining fifty-seven (57) calls were answered in under 15 minutes. Additionally, the report indicated that for all Assisted Living (AL), there were a total of five (5) call button requests that exceeded the twenty (20) minute response time. Further record review and interviews conducted revealed that the facility submitted reports for two (2) unwitnessed falls involving R1, during which R1 was sent out for medical evaluation and treatment. Interviews with staff revealed that all residents on the AL side are provided with a pendant upon admission. Staff further stated that caregivers attempt to respond to calls as quickly as possible and that medtechs also assist when needed. Additionally, per facility policy the expectation is that staff respond to pendant calls within 10 to 15 minutes. Staff further stated that residents identified as high fall risks are checked frequently, at least once every two (2) hours, totaling approximately three (3) to four (4) checks per staff member’s shift. During resident interviews, residents stated that staff generally respond promptly after pendants are activated and that staff check on them several times throughout the day.

Report Continued on LIC 9099C...

It was also alleged that staff does not ensure resident’s toileting needs are being met. It was reported that R1 attempts to manage toileting independently due to delayed staff response and not assisting in a timely manner. Record review of R1’s Physician’s Report dated 04/28/2025 revealed that R1 requires assistance with bathing, dressing/grooming, and toileting needs. Although the report indicates that R1’s mental condition may include confusion and disorientation, R1 is able to follow instructions and communicate their needs. Additionally, according to the Resident Assessment dated 01/01/2026, R1 requires stand-by assistance with toileting. Interviews conducted with staff revealed that incontinent residents are generally checked every couple of hours unless the resident’s care plan requires more frequent monitoring. Staff stated that the frequency of resident checks is determined by the resident’s assessed level of care and individual needs. It was also noted that R1 tends to become antsy and wants everything done quickly. Furthermore, during resident interviews, residents reported observing staff assisting other residents to the restroom while in the dining room. Residents also did not express any concerns regarding facility staff or living conditions at the facility. Based on the information obtained and reviewed, although the allegation may have occurred or may be valid, there is insufficient evidence to determine whether the alleged violation did or did not occur. Therefore, allegation “staff does not ensure resident’s toileting needs are being met” is deemed Unsubstantiated at this time.

No citations issued at this time. Exit interview. A copy of the report was issued.